INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2013 by staff from the of Program Licensure Division . Based on the findings of the on-site inspection, The Program for Offenders, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the facility heaters were permanently mounted or installed.
The findings included:
The physical plant inspection was conducted on June 27, 2013. During the inspection, a space heater that was not permanently mounted or installed was found in an administrative office.
The Project Director confirmed the findings.
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Plan of Correction
All heaters that are not permanently mounted or installed have been removed from the facility. The Director of Treatment Services will ensure that the heaters remain out of the facility. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill logs, the facility failed to document alternate exit routes used during fire drills.
The findings include:
The fire drill logs were reviewed on June 27, 2013. The time period reviewed was July 2012 through May 2013. The facility did not document which exits were used during fire drills during the time period reviewed.
The Project Director was interviewed on June 27, 2013 and confirmed the findings.
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Plan of Correction
The fire drill report has been changed to better document which evacuation routes were utilized during each fire drill. All reports will include this information going forward. The Director of Treatment Services will review the reports to ensure that they are completed correctly. |